Provider Demographics
NPI:1346428984
Name:MINES, DEBRA MAY
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:MAY
Last Name:MINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 23RD ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1507
Mailing Address - Country:US
Mailing Address - Phone:801-399-7255
Mailing Address - Fax:801-399-7110
Practice Address - Street 1:477 23RD ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1507
Practice Address - Country:US
Practice Address - Phone:801-399-7255
Practice Address - Fax:801-399-7110
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371631-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4254Medicaid
UT876000308011Medicaid